Paediatrician of the future: Delivering really good training - A guide to the RCPCH principles for postgraduate paediatric training and how to ...
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Paediatrician of the future:
Delivering really good training
A guide to the RCPCH principles for
postgraduate paediatric training and how to
apply them within local training programmes
Version 1.0
October 2020Paediatrician of the future: Delivering really good training - version 1.0
This is Version 1.0. As the document is updated, version numbers will be changed and content
changes noted in the table below.
Version number Date issued Summary of changes
This information is correct and up to date at the time of publication. © RCPCH 2020
2Paediatrician of the future: Delivering really good training - version 1.0
Table of Contents
Foreword 4
Executive summary 5
1. Introduction and background 7
Introduction: Training the future paediatric workforce......................................................... 7
RCPCH philosophy for training................................................................................................... 9
Workforce context........................................................................................................................ 11
2. Training principles 13
Principle 1: Every patient encounter is a learning opportunity........................................ 14
Principle 2: Complex case management provides rich learning opportunities................ 16
Principle 3: Clinical reasoning skills are explicitly taught within training....................... 18
Principle 4: Patients and families are heard........................................................................ 20
Principle 5: A biopsychosocial approach is applied at all times....................................... 21
Principle 6: Leadership skills are developed and nurtured............................................... 23
Principle 7: Training time and learning opportunities are prioritised within
the workplace ......................................................................................... 25
Principle 8: Educational supervision is high quality and provides consistency............. 26
Principle 9: Morale and job satisfaction are improved...................................................... 28
Principle 10: Assessment is used as a learning tool............................................................. 30
Principle 11: Progression and length of training are personalised and flexible.............. 31
3. Application in existing settings 33
Learning in the paediatric ward environment......................................................................... 33
Learning in the paediatric Emergency Department environment ...................................... 35
Learning in the neonatal environment...................................................................................... 37
Learning in the child development (community) service...................................................... 38
Learning in the clinic environment............................................................................................ 41
4. Development and progression 44
Using patients and parents as educators................................................................................. 44
Promoting learning in settings other than hospitals.............................................................. 46
Having an increased focus on mental health........................................................................... 47
Health promotion is an integral aspect of patient management......................................... 48
Better integrated working with primary care.......................................................................... 49
A specific focus on the health needs of young people (aged 11-25).................................... 51
Utilisation of simulation and technology-enhanced learning.............................................. 52
Teaching human factors.............................................................................................................. 54
Shared learning with other professions and disciplines........................................................ 55
Appendix 1: RCPCH Progress+ curriculum 58
Acknowledgements 59
3Paediatrician of the future: Delivering really good training - version 1.0
Foreword
The future, it is never as far away as you think it is and whenever we think about the future it is
sometimes helpful to think about what has gone before.
So here goes. Shape of Training ... three simple words which have been spoken of on many
occasions since Professor Greenaway first produced his report back in 2012. In fact, by the time
the RCPCH rolls out its new training programme fully in 2023, 11 years will have passed since the
Greenaway report. Many of you would be forgiven for thinking that this moment would never
come and yet here we are.
Again, looking back I would like to take this opportunity to remember one of my predecessors,
Dr Simon Newell who was VP for Training & Assessment back in 2012 and was first tasked with
taking this forward. Many of you will know that Simon was a Consultant Neonatologist in Leeds
and his premature passing in 2016 was felt by all in the paediatric community and I would like
to dedicate this moment to him.
It doesn’t feel that long ago since we launched the new paediatric curriculum, Progress
which is held in high regard and was in itself the major prelude to the new Paediatric Training
Programme. As I am sure you can appreciate many many hours of work have got us to this
point and I would very much like to thank all of those involved in the process from the College
staff, my fellow clinician colleagues, our children and young people and to all of those who we
consulted with and who have taken the time to not only give us their feedback but who have
embraced this exciting opportunity for paediatrics.
The Future Paediatrician document is the culmination of all of this work. It is the basis on
which really good training programmes can be constructed to get the very best out of our
trainees and the 11 principles will guide you to do just that. COVID-19 has no doubt changed the
landscape for all of those who work and train in the medical profession but if nothing else it has
reminded us that we are all flexible, versatile, resilient and above all able to adapt at speed to
any challenges presented to us and which is why I know that together across the four nations
of the UK the future of paediatric training is in safe hands.
David Evans
Vice President for Training and Assessment
4Paediatrician of the future: Delivering really good training - version 1.0
Executive Summary
The paediatrician of the future will face different challenges to those of
current consultants; healthcare is changing and the paediatric training
programme needs to adapt in order to prepare doctors for this.
RCPCH Progress, the new paediatric curriculum for excellence (RCPCH, 2018), has provided a
starting point for making these changes. The new principles for paediatric training presented
within this document, in conjunction with the new training programme structure and
guidance being introduced fully by 2023, building on RCPCH Progress to become RCPCH
Progress+. High quality paediatric training will prepare doctors to understand and support the
holistic needs of children and young people, families and populations. Paediatricians will have
an improved understanding of mental and physical health; health promotion and the social
determinants of health; and will be skilled in the care for children and young people from birth
to the age of 25 years, as appropriate and outlined in the NHS Long Term Plan (2019).
The principles outlined in this document are written for Schools of Paediatrics to describe how
they can deliver the very best training. This can begin with the resources already in place but
needs to evolve and adapt in order to be most effective, so that training adequately prepares
paediatricians for their future roles.
This document is designed as a resource guide, with ideas, illustrations and case-studies
drawn from examples of current practice across the UK. Some may be straightforward to
implement locally; suggestions are given of how to best work within current constraints
and maximise the opportunities for every trainee to access the training they want and need.
Some examples may be more aspirational but are designed to be useful prompts for those
responsible for designing training, as they consider where and how changes to the training
programmes should be targeted in future.
There are four sections within this document:
Section one:
Provides background on the RCPCH philosophy which underpins the approach to
programme and curriculum design and outlines the rationale for the development of the
RCPCH Training Principles.
Section two:
Describes the RCPCH Training Principles that should underpin all paediatric specialty
training, supported by indicators that the principle is being applied, and examples further
illustrating each principle in practice:
• Every patient encounter is a learning opportunity
• Complex case management provides rich learning opportunities
• Clinical reasoning skills are explicitly taught within training
• Patients and families are heard
• A biopsychosocial approach is applied at all times
• Leadership skills are developed and nurtured
5Paediatrician of the future: Delivering really good training - version 1.0
• Training time and learning opportunities are prioritised within the workplace
• Educational supervision is high quality and provides consistency
• Morale and job satisfaction are improved
• Assessment is used as a learning tool
• Progression and length of training are personalised and flexible
Section three:
Describes how these principles can be applied in existing training settings taking a whole-
population approach, giving examples from:
• Wards
• Emergency Departments
• Neonatal units
• Child development service (Community)
• Clinics
Section four:
Outlines how Schools can further develop their application of these principles to provide
really excellent training, detailing real life examples of novel approaches from current practice
that Schools can use to encourage greater flexibility and diversity of the training experience. The
aspirations described here will be achieved gradually over the next ten years. Some training
units will be early adopters, others will take longer.
The Learning Outcomes from RCPCH Progress+ to be achieved by all trainees are provided
within the Appendices.
We hope that this document will guide, inspire and challenge paediatricians to be a part of
training that will result in truly excellent paediatricians of the future.
..................................................
What children and young people say:
My wish for child health is that children and young people are given the power and
tools to make decisions that affect their lives. The only way to know what we want is
to ask us and talk to us.
And
We are the future. Services need us to be part of them to help them be what we
..................................................
need and this means you need to ask us and then do something with what we say.
RCPCH &Us
6Paediatrician of the future: Delivering really good training - version 1.0
1. Introduction and background
Training the future paediatric workforce
This document sets out the requirements for a training programme that meets high standards,
thereby making explicit the expectations and providing ideas for improvement for Schools
of Paediatrics who are designing programmes of training. This document, and the training
activities suggested within it, are supported by the RCPCH Trainee Charter which outlines key
elements to improve the paediatric training experience.
Postgraduate training programmes will build upon the learning experience gained from both
medical school and at foundation level. There is an expectation that medical schools and the
Foundation Training programme will continue to improve exposure to paediatric experiences,
providing students with a good grounding in the fundamental skills and knowledge required
for the management of children and young people, prior to them entering the paediatric
training programme. In order to train clinicians effectively and efficiently, and provide a
high-quality service for paediatric patients, it is crucial that all medical school curricula
incorporate a comprehensive range of paediatric elements, and provide students with
effective paediatric placements. This would benefit not only those clinicians moving into
paediatric training but also other disciplines, particularly General Practice and also Emergency
Medicine, including many surgical specialties. Further guidance on paediatric experience at
undergraduate level is provided within the RCPCH Undergraduate Curriculum.
The revised paediatric training programme is now divided into two levels. The purpose of the
first level of paediatric postgraduate specialty training, known as ‘core training’, is to ensure
that all paediatricians are equipped with the skills, knowledge and expertise required to
deliver care for infants, children and young people within a range of settings. Trainees will
continue to build on this learning throughout the second level of their training, known as
‘speciality training’, developing further in their paediatric sub-specialty (eg General Paediatrics,
Neonates etc) as well as enhancing their generic skills, knowledge and behaviours. They will
use their core experience in order to undertake holistic practice which supports and treats
the whole child or young person wherever their encounter takes place. The RCPCH Progress+
curriculum (Appendix 1) articulates the standard required by the end of both core and specialty
training.
Keeping children and young people at the
centre of everything we do
RCPCH &Us is a children, young people and family network, working with over 2000 young
patients, their families and friends across the UK. Through the work of RCPCH &Us we keep
children and young people at the centre of everything we do, supporting their voice to inform,
influence and shape the work of RCPCH.
7Paediatrician of the future: Delivering really good training - version 1.0
We are guided by the United Nations Convention on the Rights of the Child, particularly article
12 which encourages children and young people’s voice in decision making and article 24,
providing them with the best health care possible.
In the development of The Shape of Paediatric Training, we have actively sought the voice and
views of children, young people and their families. You can find out more about RCPCH &Us at
www.rcpch.ac.uk/and_us
Figure 1: Paediatric training pathway
Core Paediatrics Specialty Paediatrics
ST1 ST2 ST3 ST4 ST5 ST6 ST7
Tier 1 Transi on toTier 2 Tier 2
All trainees follow the Generic Syllabus
plus one of the specific Syllabi below:
New Core Training Programme
General Paediatrics CCT
Core curricular capabilies in
General Paediatrics, Neonatology, 70% Paediatrics
SPIN oponal
Integrated (Primary/Secondary) ST4 SPIN if done
Care, Public Health, Community trainees
Child Health, Child & Adolescent will be on
Mental Health a er 2
Sub-specialty Paediatrics
rota
Includes sub-specialty placements
Sub-specialty 1 CCT
Trainees will transion to Tier 2 Paediatrics
Sub-specialty 2 ..etc.
working by the end of ST3 with 30% (Sub-specialty)
suitable support, supervision and Sub-specialty Paediatrics
assessment
Sub-specialty 3 ..etc.
MRCPCH MRCPCH MRCPCH
Theory Clinical
START
Clinical
Entry points: post F2, F3, SAS, from other specialty programmes, etc. v4.2 Dec 2019
Within the Paediatric workforce a key challenge is to deliver more inclusive core training.
The nature of health care has changed, with an increasing focus on long term and complex
conditions, where multi-disciplinary and self-management approaches are more central
to care. Training must adapt to meet the changing population needs; the inclusion of child
and adolescent mental health and public health capabilities are now seen as vital, along with
increased emphasis on leadership behaviours and safety through well-developed clinical
reasoning. Paediatricians must deliver integrated health care for children and young
people. Integrated care should be seen as a different way of thinking about planning and
delivering care: based on people – not buildings or organisations; and based on outcomes – not
procedures or activity.
Along with this is the need to address the needs of young people (distinct from children, young
people are defined as being between the ages of 11-25 years, as outlined in the NHS Long Term
Plan, 2019). This is necessary because of the changing needs of the paediatric population and
the recognition of the importance of delivering ‘developmentally appropriate healthcare’. This
requires the development of more general paediatricians who can manage the complexity of
these patients in all age groups in liaison with specialists across all healthcare boundaries, in
particular: interfacing with primary care and mental health; supporting health in the home and
school; and focusing on young people as they transition to adult life.
8Paediatrician of the future: Delivering really good training - version 1.0
Schools of Paediatrics are required to design training programmes which take account of
current and future workforce requirements and give trainees access to a range of settings and
experiences, enabling and supporting them to meet the RCPCH Progress+ Learning Outcomes
(see Appendix 1). It is assumed that training in the acute environment, as it currently exists, will
continue, but in future will provide a broader experience for the trainee, supporting learning
opportunities within the full range of settings.
To explore in more detail how this can be achieved, this document describes:
• The RCPCH training principles, which apply to and should underpin all paediatric
postgraduate training programmes.
• How those principles can be applied within existing training settings, supported by the
Whole Population Approach (see ‘RCPCH Philosophy for Training’ below).
• Activities that can be used to enhance training, building on what happens now and
linking to the vision set out in:
• The NHS Long Term Plan for England (2019)
• The ‘Healthier Wales’ publication (2018)
• The Health and Social care delivery plan for Scotland (2016)
• Northern Ireland Quality 2020
• Quality Improvement Framework for Wales
This document seeks to capture and illustrate good practice currently taking place across the
UK, and articulate how learning should build on this, and evolve over the next ten years. The
RCPCH Progress curriculum was the first step towards implementing this new approach, and
it is anticipated that application of the principles outlined within this document will further
encourage a positive, flexible and supportive training experience for all paediatric trainees. All
case studies are mapped to the RCPCH Progress+ curriculum, indicating the domains they
may support, and possible assessment opportunities.
Delivering excellence in training comes with multiple challenges, and RCPCH acknowledges
that not all of these can be solved by and through Schools of Paediatrics. Whilst continuing
to work with Schools to set high standards and share innovative practice across the UK, the
RCPCH also puts responsibility on the Government, HEE and NHS providers to address the
wider needs of the paediatric workforce, for example lobbying for better conditions of work.
RCPCH philosophy for training
The philosophy underpinning the training pathway and curriculum for paediatrics is that of
putting the child or young person and their wider context at the heart of all clinical practice.
The RCPCH Progress curriculum moved away from a disease-based structure and instead
advocated a ‘Whole Population Approach’ that focused on symptoms, and prioritised the needs
and complexities of each individual patient and their family.
The Whole Population Approach identifies six broad patient segments, shown below. These
should be used to inform the patient pathway. There are a number of themes which would
9Paediatrician of the future: Delivering really good training - version 1.0
cut across many or all of the segments, such as safeguarding, mental health, educational
issues around school, and transition. Throughout all placements within the paediatric training
pathway, trainees should be encouraged to identify opportunities to develop their expertise in
management of patient in all segments, and their families, and these common themes.
Figure 2: A Whole Population Approach: Patient Segments in Child Health
Advice and prevention, eg Breast-feeding/
Healthy child Immunisation/ Mental well-being/ Healthy eating/
Exercise /Dental health
Vulnerable child Eg Safeguarding issues/ Self harm/ Substance misuse
/ Complex family and schooling issues
with social needs / Looked after children
Eg Depression/ Constipation/ Type 2 Diabetes/
Child with single Coeliac Disease/ Asthma/ Eczema/
long term condition Nephrotic syndrome
Eg Severe neurodisability/ Down's syndrome/
Child with complex Multiple food allergies/ Child on long-term ventilation
health needs / Type 1 diabetes
Acutely Eg Croup/ Otitis media/ Tonsilitis/
mild-to-moderately Uncomplicated pneumonia/
unwell child Prolonged neonatal jaundice
Eg Trauma/ Head injury/ Surgical emergency/
Acutely severely Meningitis/ Sepsis/ Drug overdose/
unwell child Extreme pre-term
Dr Bob Klaber & Dr Mando Watson, Connecting Care for Children (North West London)
Whilst some placements may give trainees exposure to patients in some segments more than
others, there is still the opportunity to interact with some children and young people in most or
all segments in every setting. Trainers should support trainees in thinking laterally, considering
how each of these segments would apply within any given environment.
The following example illustrates this in the context of Paediatric Intensive Care Medicine.
Examples in section 3 demonstrate how this philosophy can be applied in all training settings
(ie acute/wards, accident and emergency, neonates, community and clinics). Further case
studies throughout the document also incorporate varied examples that illustrate how these
segments are important to consider in all settings.
anticipated
10Paediatrician of the future: Delivering really good training - version 1.0
Figure 3: A Whole Population Approach worked example: PICM Meningococcal disease
Healthy child Management of prophylaxis in sibling contacts.
Vulnerable child Parent asks for support for sibling care, worried that
they cannot look after the healthy siblings and be at
with social needs the bedside during school holidays.
Acutely Initial management of meningococcal disease in the
mild-to-moderately Emergency Department; recognition, sepsis protocol
unwell child followed.
Disease progresses and need to contact PICU for
Acutely severely support in management of acute meningoccccal
unwell child disease. Discussion with parents explaining need to
escalate management and PICU support.
Workforce context
The Shape of Training report, ‘Securing the future of excellent patient care’ (General Medical
Council, 2013) calls for a flexible and adaptable workforce that is trained to meet the changing
population needs. Whilst adapting to these changing patient and service needs, paediatrics is
facing significant workforce challenges which impact both on training experience and patient
care, including:
Rota gaps:
To meet the Facing the Future standards, providing safe care for children and young
people and keeping up with rising demand, the RCPCH has calculated that we would need an
additional 850 whole time equivalent (1104 headcount) consultants and that approximately 150
more doctors must be recruited into ST1 training posts each year for the next five years.
Workload pressures:
Heavy workloads remain an issue, although there are some welcome signs of improvement
in this area. Since 2016 the proportion of trainees who say they worked beyond their rostered
hours on a daily basis, has halved (from 18.3% to 9.1%).
Service provision:
The balance of service provision/training has shifted towards service provision because of
unfilled rotas and patients with increasingly complex medical conditions. This needs a long
term, sustainable, multidisciplinary solution to enable trainees to train and prepare adequately
for life as a consultant.
11Paediatrician of the future: Delivering really good training - version 1.0
Flexible working patterns and choice:
37.7% of paediatric trainees are now working less than full time (General Medical Council, The
state of medical education and practice in the UK 2018). We need to be a modern, forward
thinking and “family-friendly” specialty that allows for flexible working, including Out of
Programme (OOP) and Out of Programme Pause (OOPP), where possible.
Protected time for trainers:
Trainers have variable time to provide excellent clinical and educational supervision. The RCPCH
supports a framework for Educational Supervisor accreditation. It is important that trainers
and supervisors understand the roles they are performing and feel valued in them.
The principles within this document are designed to ensure paediatrics provides consistently
high quality training for all junior doctors within the specialty, which will go some way to
addressing these issues. Therefore, it is vital that NHS Employers, Deaneries/Local Education
and Training Boards (LETBs) and Trusts are committed to supporting Heads of Schools in
enacting these principles in full.
12Paediatrician of the future: Delivering really good training - version 1.0
2. RCPCH Training principles
This section outlines the key underlying RCPCH principles of excellent training:
1. Every patient encounter is a learning opportunity
2. Complex case management provides rich learning opportunities
3. Clinical reasoning skills are explicitly taught within training
4. Patients and families are heard
5. A biopsychosocial approach is applied at all times
6. Leadership skills are developed and nurtured
7. Training time and learning opportunities are prioritised within the workplace
8. Educational supervision is high quality and provides consistency
9. Morale and job satisfaction are improved
10. Assessment is used as a learning tool
11. Progression and length of training are personalised and flexible
For each principle, an explanation is provided of what the RCPCH deems to be an acceptable
standard that every training programme should be providing. This is followed by examples
indicative of good practice, which are designed to help Schools of Paediatrics judge whether
they are meeting the stated principle. Each principle is also supported by a range of practical
case studies drawn from real working environments, serving as further prompts for Schools
looking for opportunities to embed and promote the principle.
Additional suggestions for implementation and development of the principles are provided
within sections 3 and 4.
13Paediatrician of the future: Delivering really good training - version 1.0
Principle 1: Every patient encounter is a
learning opportunity
Schools should develop a faculty that encourages learning from each and
every patient and family encounter
“It is helpful to have lists of opportunities to become involved in which improve access to
educational opportunities rather than having dead time. One example has been that we
have had a list of children whom locum consultants had asked for follow up for. When
registrars have had normal days and the ward is well staffed, they have been able to
access this list and do ad hoc phone consultations with parents, deciding if children could
be discharged, needed further investigation or management, or needed to be seen face to
face. This has increased trainee involvement in outpatient work which is often put on the
back burner as inpatient work is seen as the priority.” Trainee ST4
Every patient and family encounter should be approached as a learning opportunity. Trainees,
working hard to deliver a service, are also developing themselves as paediatricians. They should
be directed and encouraged to engage with those presentations that will provide the greatest
relevance to their training requirements and also need to be reminded that there is something
to learn from every patient they see. The trainee should also have the ability to allocate time to
debrief and reflect with the trainer on these encounters. The trainee must take ownership of
these learning activities but will benefit from guidance by their trainers.
Examples indicative of good practice:
• Trainees and Supervisors routinely discuss learning outcomes before and after outpatient
clinic, and at the end of the ward round, the trainees should ask ‘what did I learn from this
case and how could I have done better?
• When ordering an investigation, the trainee actively considers the risks and benefits for
the patient and family and can access advice from senior colleagues.
• When trainees encounter a well child (eg a baby check), they should consider the role of
the paediatrician in health promotion opportunities.
• Rota designs give trainees opportunities to follow the patient journey rather than just
getting a snapshot of their care.
• Trainees routinely discuss communication techniques with their Supervisor around
breaking bad news.
• Trainees regularly use cases to teach medical students, foundation trainees and more
junior trainees, both ad hoc (eg on a ward round) or through presenting a case during
handover.
14Paediatrician of the future: Delivering really good training - version 1.0
Case studies:
Case study Evidence RCPCH Progress+ domain
1.1 As a way of amplifying learning around critically CbD 4. Patient management
unwell children, the consultant makes use of Reflection 11. Research & scholarship
the most acute cases, eg pneumonia or septic
arthritis, and directs trainees to related high-
quality e-learning resources and evidence-based
literature.
1.2 The trainee assesses babies with prolonged CbD 4. Patient management
neonatal jaundice and discusses the cases each Reflection 5. Health promotion & illness
week with the consultant. Each case is used to prevention
explore common issues around breast-feeding, 11. Research & scholarship
normal infant bowel habits, perinatal maternal
mental health and the role of the health visitor in
supporting families.
1.3 Trainees consider which imaging reports and CbD 4. Patient management
investigations are useful to flag for the x-ray Reflection
meeting as teaching cases and not solely
presenting for clinical discussion. These examples
can be used to teach the approach to ordering
investigations, to consider how to balance risks
and benefits of investigations and develop an
understanding of the practicalities of the
imaging, explaining the investigation to patients
and families and knowing how to interpret
findings.
..................................................
What children and young people say:
We would like you to think about all the hidden health needs for both us as the
patient and our family. This includes hidden conditions, the hidden impact on our
parents and carers and the services which are hidden from us that could really help.
We had a parent group who created a #HiddenHealth[*] toolkit that you can use, that
gives a list of questions for doctors to think about when working with patients and
families.
..................................................
* www.rcpch.ac.uk/hiddenhealth
#voicematters
15Paediatrician of the future: Delivering really good training - version 1.0
Principle 2: Complex case management
provides rich learning opportunities
Schools should develop faculty that encourages breadth of learning from
complex cases
Within paediatrics, trainees can learn from different types of complex cases. Trainers should
make these opportunities accessible to trainees and encourage their understanding of the
complexities of paediatric assessment and care.
One important example of this is safeguarding, which is an opportunity to learn holistic child
health, integrating multiple clinical skills. In safeguarding medicals, clinicians have to take
into account the whole picture, thinking about public health, the multidisciplinary team (MDT)
and social issues. It is an exemplar of holistic clinical activity; trainees should be encouraged
to understand the linkage between different perspectives and how that translates to other
aspects of paediatrics.
The skills learnt from managing a medically complex child with severe disability or a severely
unwell child in an intensive care setting are different, but equally important.
Examples indicative of good practice:
• Trainees take part in a shadowing opportunity to see non-acute safeguarding cases,
eg shadowing a social worker, nurse, midwife or health visitor who is undertaking
safeguarding work.
• Medically complex cases are now more prevalent on wards and need to be supported in
and out of hospital. Trainees are given responsibility for ward round reviews, discharge
planning meetings and following these patients up outside of the hospital setting.
• Trainees work with CAMHS on cases such as eating disorders, drug overdose in the
context of family psychosocial dysfunction, and challenging behaviour.
• Trainees are given the opportunity in the child development centre to participate in a
comprehensive review of patients with severe neurodisability.
• Trainees are confident in using research to inform evidence-based practice, referring to
guidelines, standards or other literature.
• Trainees are encouraged to share their learning from complex cases with their colleagues.
Case studies:
Case study Evidence RCPCH Progress+ domain
2.1 The trainee sees children and families in the CbD 2. Communication
acute setting, and considers the whole social MiniCex 4. Patient management
background. For example, a child with a Reflection 5. Health promotion &
pneumonia is seen acutely, and is noted to have illness prevention
severe dental caries. On further questioning, the 9. Safeguarding
mother tells the trainee she has three other
children and is struggling to cope. The trainee
links in with the health visitor, the GP and the
social worker to provide appropriate support.
16Paediatrician of the future: Delivering really good training - version 1.0
Case study Evidence RCPCH Progress+ domain
2.2 Palliative care represents an opportunity for rich CbD 4. Patient management
learning. A child with a life limiting condition is MiniCex 6. Leadership & team
seen on the paediatric ward with an intercurrent Reflection working
illness. The trainee takes the opportunity to 10. Education & training
review what support is being offered to the
family (carers in the home, local nursing services,
respite, social care support, voluntary agencies/
charities) and considers what other support may
be available to them. The trainee also reviews
the advance care plan and arranges a meeting
between the consultant and parents (and child if
old enough) to update this.
2.3 A weekly MDT meeting is held where two - three MSF 4. Patient management
of the most challenging cases are discussed. CbD
Presented by trainees, cases are selected if they MiniCex
provide diagnostic, managerial or safeguarding
challenges, or simply have a really good learning
point. The session is very well attended with con-
sultants from different specialities, any trainees
who are free, and multiple other members of the
MDT. This allows for brainstorming of ideas and
sharing of learning which is great for trainees and
for patients!
..................................................
What children and young people say:
It is really important to us that doctors see the whole person in front of them, not
just a medical thing that needs fixing. Please remember to talk to us about how we
are feeling and coping (mental health) and share with us apps that help us to track
our medicines and emotions like the ones in the NHS Apps Library[*]. Also think about
who else can help us locally from charities or support groups for our conditions or
supporting things like poverty.
..................................................
* www.nhs.uk/apps-library/
#voicematters
17Paediatrician of the future: Delivering really good training - version 1.0
Principle 3: Clinical reasoning skills are
explicitly taught within training
School faculty should encourage trainees to develop their clinical
reasoning skills by applying the methods of clinical reasoning to create a
differential diagnosis
Clinical reasoning is a process by which clinicians collect cues, process the information, come to
an understanding of a clinical problem, plan and implement interventions, evaluate outcomes,
and reflect on and learn from the process. Simply put, it is an intellectual process leading to a
‘working diagnosis’ and a clinical management plan.
Clinicians should encourage trainees to develop a range of clinical reasoning techniques, such
as pattern recognition and formulation and challenge of differential diagnoses.
Examples indicative of good practice:
• Trainees are encouraged to consider a differential diagnosis for each patient they assess
and to present evidence that helps refute or confirm these.
• Trainees are given the opportunity to assess a wide range of common conditions to
improve their pattern recognition abilities.
• Trainees get exposure to clinical cases that demonstrate pathognomic signs and symptoms.
• Trainees always keep an open mind and consider a wide range of differential diagnoses,
but equally have the confidence and competence to make a diagnosis.
Case studies:
Case study Evidence RCPCH Progress+ domain
3.1 The trainee presents a case on the ward round. CbD 2. Communication
The consultant pauses after the history and asks MiniCex 4. Patient management
the team to suggest a differential diagnosis and Reflection 10. Education & training
discuss the key elements of the examination to
support or refute these first ideas. The consultant
then points out the clinical reasoning that under-
pins the discussion before asking the trainee to
continue with the presentation.
3.2 On the ward there are a number of patients with CbD 2. Communication
asthma; some are very similar and some are MiniCex 4. Patient management
slightly different. At the end of the ward round, Reflection 10. Education & training
the consultant has a reflecting learning
conversation with the team to explore these
patterns and signpost how people can build up
their own internal library of patterns on the basis
of their experience and existing knowledge.
3.3 The consultant signposts when a particular CbD 2. Communication
finding almost guarantees a certain diagnosis. MiniCex 4. Patient management
For example, the combination of short stature, Reflection 10. Education & training
webbed neck and increased carrying angle in
a female suggests Turner syndrome and cases
when it does not.
18Paediatrician of the future: Delivering really good training - version 1.0
..................................................
What children and young people say:
It is good when you use your skills to help us understand what is going on, eg a
young person with cerebral palsy and limited speech likes it when they are talked to
directly and when the consultant emails before with questions and information. A
child with epilepsy liked it when they got a copy of the brain scan which was drawn
all over by the doctor to explain what happens. A young person said about how the
..................................................
doctor used easier words and did a drawing to explain what was going on.
#voicematters
Principle 4: Patients and families are heard
Schools should develop faculty that encourage and promote
person-centred care
Patients and their families should form the centre of learning for trainees. Too often, patients
and families are seen as passive recipients of care; instead they should be seen as a resource
to support their self-management, to support each other and to be experts in their own care.
All trainees should attempt to explore the wider context and meaning of health and illness for
families, as part of a holistic approach.
Examples indicative of good practice:
• Trainees have the opportunity to follow patient journeys over a prolonged period, and in
different settings, reflecting on the impact of their interventions.
• Trainees learn techniques to help them draw out and amplify the patient voice.
• Trainees use patient feedback on outcomes relevant to them as part of a quality
improvement project.
• Trainees understand involvement of children and young people at individual, service and
strategic levels.
19Paediatrician of the future: Delivering really good training - version 1.0
Case studies:
Case study Evidence RCPCH Progress+ domain
4.1 The consultant prompts the trainee to discuss the CbD 2. Communication
non-medical aspects of a case with the family and Reflection 5. Health promotion &
how the illness affects them. For example, rather than illness prevention
focussing on their medical condition, what does their 6. Leadership & team
illness mean to them and their family? How many working
medicines do they have to take a day? What do they 7. Patient safety
need to take on holiday? Can they go for sleepovers?
What effect do healthcare appointments have on
their parents’ working lives and careers? What about
their siblings? The trainee is encouraged to talk about
the experience of healthcare for families – how many
different people do they see? How many different
appointments in different places? This is done in a
non-clinical setting or in a patient’s home.
4.2 Trainees complete an emotional mapping exercise CbD 2. Communication
charting a family’s experience of healthcare/patient Reflection 4. Patient management
journey, and use this to try and make improvements 5. Health promotion &
to services. illness prevention
11. Research & scholarship
4.3 A “What matters to us” exercise is undertaken by Reflection 8. Quality improvement
a trainee when trying to work out how adolescent
services for diabetes should develop locally. Young
people who use the current service are encouraged
to share their views at their visits. This information is
then used by a group of young people working with
staff to support the redesign of services.
..................................................
What children and young people say:
Ask us! We have lots of ideas and if asked in the right way, we can help you to under-
stand more about what is happening for us but also ways to help make your service
the best it can be. We have made resources about being LGBT+ in health services[*]
about transition[**] or on getting ideas on service design[***]. The RCPCH &Us team can
advise too – email them at and_us@rcpch.ac.uk and maybe you can come and meet
us!
* www.rcpch.ac.uk/rainbow-health-supporter
..................................................
** www.rcpch.ac.uk/resources/young-peoples-experiences-health-transition
*** www.rcpch.ac.uk/resources/recipes-engagement-children-young-people-lead-rcpch-us
#voicematters
20Paediatrician of the future: Delivering really good training - version 1.0
Principle 5: A biopsychosocial approach is
applied at all times
Schools should develop faculty that understands and can teach a
bio-psychosocial approach
“My TPD’s were incredibly accommodating in helping me to achieve my unusual training
requirements. The really positive thing is that after I had done the placements, work was
done to create permanent placements for paediatric trainees in CAMHs, and so other
trainees have also benefitted from this, as have the children who have experienced a
more integrated approach.” New Consultant
Medicine traditionally relies on categorical diagnoses, which are supposed to map to specific
pathology, and explain the symptoms of a child who has been placed in that category.
However, clinical experience teaches us that this is an imperfect model - children in socially
vulnerable situations, experiencing negative emotions or with family dynamic issues are all
prone to suffer more symptoms, whether or not a pathology has been identified. Also, many
diagnoses are essentially clusters of symptoms without identifiable pathology, meaning that
these ‘psychosocial’ factors can add greatly to the efficacy of paediatric practice by altering the
context in which symptoms are experienced.
Examples indicative of good practice:
• Trainees are encouraged to consider the psychosocial situations of all patients and
families.
• Trainees attend and contribute to psychosocial/MDT meetings where these are held.
• Trainees have opportunities to spend time with the CAMHs teams and to attend some of
their sessions.
• The School delivers teaching on psychosocial aspects of illness as part of their curriculum
delivery.
Case Studies:
Case study Evidence RCPCH Progress+ domain
5.1 A 14 year old young man is seen in clinic for review of CbD 4. Patient management
asthma management after two recent admissions. Reflection 5. Health promotion &
The trainee undertakes HEADDSS assessment which illness prevention
enables the young man to discuss his smoking and
cannabis use and their impact on his asthma. Taking
regular inhalers has been challenging as he is living
between three homes, his mother’s, father’s and
girlfriend’s. The trainee and patient develop a
management plan together.
21Paediatrician of the future: Delivering really good training - version 1.0
Case study Evidence RCPCH Progress+ domain
5.2 The trainee sees a patient who has a persistent CbD 4. Patient management
headache without obvious cause. They take a Reflection 5. Health promotion &
history and construct from it a formulation of the illness prevention
predisposing, precipitating and perpetuating
factors underlying their symptoms, as well as any
protective factors within the patient and family
which could be exploited to aid recovery.
The consultant and trainee work together exploring
these psychosocial issues with the patient and then
to negotiating an understanding of the patient’s
difficulties with her family and the rest of the
professional network, incorporating biological and
psychosocial aspects of her history and
presentation.
5.3 The trainee attends a working group set up between CbD 5. Health promotion &
CAMHS and paediatrics to look at improving the care Reflection illness prevention
and experience of young people attending ED 6. Leadership & team
following self-harm. They lead on engaging young working
people and gathering data on their experience and
suggestions for improvement.
The trainee learns the complexity of the relationship
between CAMHS and paediatrics, and the barriers
that need to be overcome to achieve joint working.
..................................................
What children and young people say:
Having healthcare workers that understand our emotional health and wellbeing is
important to us. We know that children and young people with long term conditions
struggle more with their mental health, and that we can find it difficult to talk to you
about it when you are busy, and we have things like our medicines to talk about. We
have made resources that help us to share what we are feeling like the emoji cards[*]
or the feelings posters[** ].
..................................................
* www.rcpch.ac.uk/resources/emoji-card-game
** www.rcpch.ac.uk/being-men
#voicematters
22Paediatrician of the future: Delivering really good training - version 1.0
Principle 6: Leadership skills are developed
and nurtured
Schools should develop a faculty that supports and enables leadership
development for all trainees, appropriate to their training level
“Doing clinical work alongside service improvement and development has been
something I have really enjoyed during this time period. For me, each aspect has informed
the other – the service improvement work improving my knowledge and broadening my
experience, and my clinical work informing my ability to input into service development”.
Trainee ST4
Trainees of today are the consultants of the future and need to be better prepared to adapt
into this role. The paediatric curriculum encourages the development of leadership skills from
the very first day of training, and all trainees should have the opportunities to practice and
improve these skills at every training stage.
Trainees should also develop skills required to support quality improvement. Quality
improvement needs to be seen from the perspective of improving clinical outcomes but
also improving those things not directly related to clinical management, eg service delivery,
delivery processes, efficiency in the workplace.
Examples indicative of good practice:
• The consultant regularly takes time to speak with trainees, sharing clinical and non-clinical
insights from their day’s work.
• Ward rounds and day time work are used to give trainees opportunities to practice
leadership skills under direct supervision.
• The School hosts regional training events focused on aspects of leadership and
management.
• All trainees are encouraged to participate in quality improvement projects during each post.
Case Studies:
Case study Evidence RCPCH Progress+ domain
6.1 ST3 trainees “act up” to registrar level, in a supported Leader 6. Leadership & team
way during day time hours, or on the weekends. This HAT working
may involve trainees leading a ward round, where the ACAT
consultant and trainee agree explicit objectives (eg Reflection
involvement of nurses, timeliness, prioritisation) at the
beginning of the round, and at the end of the round
spends some time to debrief around these objectives.
Another option involves the consultant and registrar
to swap roles during a ward round, giving the trainee
an opportunity to lead the ward round under direct
supervision; time is spent afterwards to discuss the
experience.
23Paediatrician of the future: Delivering really good training - version 1.0
Case study Evidence RCPCH Progress+ domain
6.2 Consultants regularly share details of their Leader 6. Leadership & team
leadership responsibilities with trainees and Reflection working
encourage them to take a leadership role in
each post, eg running junior doctor teaching
programme, being a junior doctor forum rep, or
trainee representative on the medicines committee.
Departments also keep a list of quality
improvement projects that they are led by trainees.
6.3 A child is seen in clinic with developmental delay. The Leader 4. Patient management
registrar carries out a full history and examination Reflective 6. Leadership & team
and arranges for them to be seen by other members event working
of the MDT (physio, OT, SLT, portage). Following a
period of assessment by all allied health professionals,
the registrar arranges and chairs a family support
planning meeting (a meeting for the parents with
all involved professionals) to share their findings and
make a plan about how best to support the child
and their family. The written plan is shared with all
involved following the meeting.
..................................................
What children and young people say:
We need health workers to take the lead and make sure everyone is linked up and
working together. It can be really hard work for us when there are lots of different
people involved and different computer systems or different locations to remember
everything. Sometimes we need you to speak up for us to other teams or help to get
the right support in schools. Your leadership skills help us feel confident it what is
..................................................
happening and that we are all doing this together.
#voicematters
Principle 7: Training time and learning
opportunities are prioritised within the
workplace
Schools should ensure that trainees are placed in posts that provide a
programme of core training which balances service provision with the
opportunities for learning
The new model for paediatric training will provide opportunities for high quality training
provision, undertaking activities which promote high educational value and impact. Trainees
24Paediatrician of the future: Delivering really good training - version 1.0
should be encouraged to identify and utilise learning opportunities that naturally occur within
their day to day roles. If all principles are properly applied to trainees’ work, it is likely that most
‘service work’ becomes educational, as long as there is a mechanism for feedback. Emphasis
will be placed upon working more effectively with other professionals; this could mean the
delegation of tasks to best meet the skills required.
Examples indicative of good practice:
• The use of a multi-professional workforce is promoted within paediatric departments to
ensure non-training tasks can be delegated away from paediatric trainees.
• Rota designs that offer training/education weeks or engagement with wider training
opportunities.
• Placement of trainees in the same trust for at least one year.
• Consultants proactively encourage trainees to identify opportunities for completing
Supervised Learning events (SLEs) within clinics, ward rounds etc.
• Rota designs give trainees opportunities to follow the patient journey rather than just
getting a snapshot of their care.
• Trainees are actively encouraged to develop their own skills in teaching and developing
others.
Case studies:
Case study Evidence RCPCH Progress+ domain
7.1 A local GP training scheme wants to give more CbD 4. Patient management
trainees experience of paediatrics. GP training posts Reflection 5. Health promotion &
are re-assigned from surgery to paediatrics and the illness prevention
expansion of the rota enables each trainee to have 8. Quality improvement
two or three weeks of ‘education’ time per rotation.
This provides dedicated time for trainees to attend
clinics and to carry out quality improvement projects
with primary care colleagues.
7.2 Whilst consultants are present, certain ward rounds HAT 6. Leadership & team
each week are designated as being trainee-led, with Mini-Cex working
direct supervision and immediate feedback of Reflection
clinical practice from attending consultant.
Supervised Learning Events (SLEs) are completed in
real time, allowing training whilst providing service.
7.3 Non-training tasks are delegated to other health care N/A N/A
professionals. For example, once a week, a senior
midwife completes baby checks so that juniors can
attend teaching. During this time a consultant would
carry the crash-bleep such that training is truly
protected. Other examples include paediatric
phlebotomists taking routine bloods, and physician
assistants seeing routine admissions and complete
discharge summaries.
25Paediatrician of the future: Delivering really good training - version 1.0
..................................................
What children and young people say:
We want you to know what it is like to be a child or young person today. It would be
good if you learn from us about our (fun) lives, the TV programmes we watch, how to
make slime, the way social media is used (for good and bad), the pressures some of
us have with our families/identity/school work, what we like and how to include this
knowledge into your work. Have a look at our top tips for doctors[*] for more ideas.
..................................................
*www.rcpch.ac.uk/beingme
#voicematters
Principle 8: Educational supervision is high
quality and provides consistency
Schools should ensure that trainees are supported by well-trained faculty,
including expert Educational Supervisors, and a learning culture is
encouraged in the workplace supported by trainers from all disciplines
and professions
Wherever possible, trainees should have the same Educational Supervisor throughout core
training, and a consistent Educational Supervisor through higher level (specialty) training,
providing longer term support and understanding of their developmental needs. Educational
Supervisors and trainers from paediatrics and other professional backgrounds will maximise
learning opportunities for the trainee and create a thriving learning environment.
The supervisor role is one that enables the trainee to flourish, providing a balance between the
development of autonomy within their role. This allows trainees to be accountable for their
actions within the clinical environment while still being supported and nurtured.
Examples indicative of good practice:
• Schools and training units take care when pairing trainees with their supervisors.
• The School hosts a faculty development programme to foster high-quality facilitation and
feedback (eg case study 23.2).
• Schools work towards supporting educators as outlined by the HEE quality framework
2017/18 (https://www.hee.nhs.uk/our-work/quality).
• Feedback is part of everyday activity. Trainees and Clinical Supervisors are encouraged to
give feedback and reflect on daily activities and to seek 360o feedback from others on a
regular basis.
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